Wheat bran- but not oat bran-enriched diets increase the mucosal height of the cecum and colon of newly weaned and aged rats

BACKGROUND: The quality of pain relief during the first 48 hours following ambulatory surgery has been poorly documented. This questionnaire study was performed to evaluate the nature and severity of pain after the patient leaves the hospital. METHODS: 1100 patients in the age group 5-88 years who underwent ambulatory surgery during a period of 6 months were asked to complete a questionnaire 48 h after the end of the operation. In the case of children, parents were asked to complete a similar questionnaire. The questions were related to pain experienced during the first 48 h after surgery and to the nature and severity of postoperative complications. RESULTS: A total of 1035 out of the 1100 patients returned the questionnaire, 94.1%. Overall the majority (65%) of patients had only mild pain at home; however, patients undergoing certain types of surgery had moderate-to-severe pain: inguinal hernia surgery (62% patients), orthopaedic surgery (41%), hand surgery (37%) and varicose vein surgery (36%). In these patients the severity of pain did not decrease during the 2-day study period. About 10% patients had more severe pain than they had anticipated, and 20% had difficulty in sleeping at night due to severe pain. Despite this, over 95% of patients were satisfied with management of postoperative pain. Nausea (20%), tiredness (20%) and vomiting (8%) were the commonest complications reported during the first 48 h. A significant association was found between the administration of a general anaesthetic and the incidence of nausea postoperatively. A large number of patients were alone at home after the operation (28.4%); some (3.8%) had no access to a relative or friend in case of need. CONCLUSION: Our results show that about 35% of day-surgery patients experience moderate-to-severe pain at home in spite of analgesic medication. About 20% of patients had sleep problems due to severe pain. However, only 5% of patients were dissatisfied. Better analgesic techniques are necessary for patients undergoing certain types of surgery. Patient information and follow-up routines need to be improved.     

Extent and severity of periodontal destruction based on partial clinical assessments

OBJECTIVES: To evaluate the postoperative analgesic efficacy, side effects and acceptance by patients and nurses of intravenous "patient-controlled analgesia" (PCA) with morphine, metamizole and buprenorphine. MATERIAL AND METHODS: In this randomized double blind prospective study of 150 patients in three groups receiving morphine (group A), metamizole (group B) or buprenorphine (group C), the patients had undergone low abdominal surgery with the same anesthetic protocol. Pain was recorded during the first 48 h after surgery on an orally-communicated scale of none or slight = 0, moderate = 1 and severe = 2. Upon the first report of moderate pain, patients were administered an intravenous bolus containing 5 mg morphine, 1 g metamizole or 0.15 mg buprenorphine. A perfusion pump was then connected and set with one bolus of 1.2 mg morphine, one of 333 mg metamizole or one of 0.04 buprenorphine. The maximum dose allowed in 24 h was 40 mg morphine, 8 g metamizole or 1.2 mg buprenorphine. The minimum interval between doses was 30 min for all three groups. Side effects reported were respiratory depression, sedation, nausea, vomiting, pruritus, perspiration and pain upon administration. Patients and nurses were asked to evaluate the system when the pump was disconnected and the results were then analyzed statistically. RESULTS: The analgesic effect was satisfactory in all three groups, with no significant differences among them. The percentages of patients reaching the maximum allowed dose on the first day were 2% with morphine, 18% (p < 0.05) with metamizole and 8% with buprenorphine. No respiratory depression was observed. Sedation was greater with morphine and buprenorphine than with metamizole (p = 0.0001). Pruritus was also greater with morphine and buprenorphine than with metamizole (p = 0.02) and pain upon infusion was greater with metamizole (p = 0.0002). CONCLUSIONS: Intravenous postoperative PCA was effective with all three drugs studied. Patient and nurse acceptance was good and side effects were few in the three groups. The lower rate of side effects for metamizole makes it the drug of choice.     

Observations on the zinc protoporphyrin/heme ratio in whole blood

The aim of this study was to examine whether severity of preoperative pain intensity is related to postoperative pain and morphine consumption. Sixty consecutive patients scheduled for total hip surgery during intrathecal anesthesia were studied. Preoperative visual analog scale (VAS) scores and analgesic intake was assessed 1 day before surgery. Three groups of patients were identified: those with mild pain (n = 12, VAS score 0-4), moderate pain (n = 18, VAS score 4-7), and severe pain (n = 28, VAS score 7-10). Postoperative pain scores were recorded in the first 24 h, as was the amount of morphine delivered by the patient-controlled analgesia pump. There were no differences among the groups in VAS scores at any time. Severe preoperative pain levels correlated with significantly greater postoperative morphine intake. The mean morphine intake during the first 24 h postoperatively was 19.2 mg in the mild pain group, 21.2 mg in the moderate pain group, and 29.5 mg in the severe pain group (P < 0.05 compared with both other groups). We conclude that patients with severe preoperative pain self-medicate to achieve postoperative pain scores equivalent to those of patients with mild and moderate pain and require a greater postoperative morphine intake for adequate analgesia than patients with mild or moderate preoperative pain. IMPLICATIONS: In this study, we showed that severity of preoperative pain intensity relates to postoperative pain levels and morphine consumption. Patients scheduled for total hip surgery with severe preoperative pain require more postoperative morphine in the first 24 h.     

Phosphatidylcholine-associated aspirin accelerates healing of gastric ulcers in rats

In this double-blind study, we administered lumbar epidural bupivacaine or bupivacaine plus verapamil to investigate the possible role of the calcium channel blocker, verapamil, in postoperative pain. One hundred patients (ASA physical class I or II) scheduled for lower abdominal surgery were randomly assigned to one of four groups. Group 1 received 10 mL of 0.5% epidural bupivacaine injected 15 min before incision, followed by 10 mL of epidural normal saline 30 min after incision. Group 2 received 10 mL of epidural normal saline injected before incision, followed by 10 mL of 0.5% epidural bupivacaine 30 min after incision. Group 3 received 10 mL of 0.5% epidural bupivacaine plus 5 mg of verapamil injected before incision, followed by 10 mL of epidural normal saline 30 min after incision. Group 4 received the same drugs as Group 3, in the reverse order. Pain and mood numeric rating scores, sedation scores, Prince Henry scores, patient-controlled cumulative postoperative analgesic consumption, and the incidence of side effects were assessed 2, 6, 12, 24, and 48 h after the operation in each group. Cumulative postoperative analgesic consumption in Groups 3 and 4 was significantly lower (P < 0.05) than that in Groups 1 and 2 24 and 48 h after surgery. There were no differences in the pain, mood, and sedation scores and the incidence of side effects among the four groups. We conclude that epidural verapamil decreases postoperative pain, possibly by interfering with normal sensory processing and by preventing the establishment of central sensitization. Implications: Calcium plays an important role in pain physiology at the spinal cord level. We examined the effect of bupivacaine plus verapamil (calcium channel blocker) and of bupivacaine alone. We demonstrated that the combination, administered epidurally, resulted in less postoperative analgesic consumption than bupivacaine alone.     

Prescription and use of analgesics in dogs and cats in a veterinary teaching hospital: 258 cases (1983-1989)

The frequency of prescribing analgesics and administering them for the treatment of apparent postoperative pain in 243 dogs and 15 cats was evaluated. Surgeries performed on the animals evaluated included limb amputations, limb-sparing bone cancer resection, thoracotomy, cervical vertebral instability repair, and humeral fracture repair. Only 1 cat was treated once with an analgesic after surgery, and cats were not evaluated statistically. Dogs undergoing amputation, limb salvage procedure, or thoracotomy were more likely to be treated than dogs undergoing the other surgeries. Ninety-six (40%) of the 243 dogs were under the influence of an analgesic at any time during their postoperative hospital stay, and 69 dogs (28%) received 1 or more doses of an analgesic after recovery from general anesthesia. One hundred thirty-three dogs were cared for in the intensive care unit (ICU) immediately after surgery. Written instructions for treatment with an analgesic were given for 61 of those dogs, and 50 were given at least 1 dose of the prescribed analgesic. Dogs cared for in the ICU were twice as likely to be given an analgesic as dogs cared for in the surgery ward. The estimated duration of analgesic effect exceeded 8 hours in 46 (19%) of 243 dogs. Small and juvenile dogs were least likely to be treated. Interns and residents were twice as likely as faculty to administer analgesics. Most written interpretations of pain behavior observed in the ICU were made on the basis of vocalizations. Half of the dogs for which medical record comments suggested moderate to severe pain were not given an analgesic. The most frequently administered analgesic immediately following surgery was oxymorphone, followed by butorphanol and morphine. Aspirin was never administered to dogs in the ICU, but was used in 10 dogs that were in the surgery ward for > 74 hours.     

Intraoperative intravenous ketamine in combination with epidural analgesia: postoperative analgesia after renal surgery

We designed this double-blinded, randomized, controlled study to evaluate the effect of small-dose ketamine IV in combination with epidural morphine and bupivacaine on postoperative pain after renal surgery. An epidural catheter was inserted, and the administration of morphine and bupivacaine was started before surgery. Forty patients were assigned to one of two groups (ketamine or control). The ketamine group was administered a ketamine bolus and infusion during surgery. The median visual analog pain scale (VAS) scores at rest were significantly lower in the ketamine group during the first 6 h (P < 0.01). VAS pain scores on coughing were also significantly lower in the ketamine group (P < 0.01). Cumulative postoperative total analgesic consumption was less in the ketamine group on Days 1 and 2 (P < 0.001). The first analgesic demand time was shorter in the control group (9.2 +/- 11.5 min) than in the ketamine group (22.3 +/- 17.1 min) (P < 0.0001). The incidence of nausea and pruritus was more frequent in the control group (P < 0.05). In conclusion, postoperative analgesia was more effective when spinal cord and brain sensitization were blocked by a combination of epidural morphine/bupivacaine and IV ketamine. IMPLICATIONS: Renal nociception conducted multisegmentally by both the spinal nerves (T10 to L1) and the vagus nerve cannot be blocked by epidural analgesia alone. We demonstrated that IV ketamine had an improved analgesic or opioid-sparing effect when it was combined with epidural bupivacaine and morphine after renal surgery.     

Frequency, intensity, development and repercussions of postoperative pain as a function of the type of surgery

Type of surgery is the most important factor conditioning intensity and duration of postoperative pain. Thoracic and spinal surgery are the most painful procedures. Abdominal, urologic and orthopedic surgery lead to severe postoperative pain. Duration of severe pain rarely exceeds 72 hours. Mobilization increases pain intensity after abdominal, thoracic and orthopaedic surgery. Pain could occur after daycase minor surgical procedures and is often underestimated. Postoperative complications related to pain are difficult to disclose because of the interposition of the direct effects of analgesic treatments. Respiratory and cardiovascular postoperative complications are unrelated to postoperative pain in healthy subjects. This could be different in high risk patients. The surgical procedure is the major determinant of metabolic and psychologic postoperative deterioration. Adequate pain relief allows postoperative rehabilitation and physiotherapy programmes after abdominal and orthopaedic surgery. This could be expected to reduce hospital stay and improve convalescence.     

Leptin activates hypothalamic CART neurons projecting to the spinal cord

Interviews were conducted with 265 orthopedic and chronic pain patients, using a structured diagnostic instrument (ADDIS/SUDDS) concerning their use of analgesics. Twenty-two percent of the patients met criteria for analgesic use disorders in accordance with DSM-III-R; 18.5% fulfilled DSM-IV criteria. Dextropropoxyphene was the most common analgesic prescribed and was used by 47% of the patients who met criteria for analgesic use disorders. It is concluded that patients with chronic pain using narcotic analgesics are at considerable risk of developing analgesic use disorders. Assessment of the use of analgesics should be offered to pain patients taking narcotic drugs.     

Sleep-promoting effects of melatonin: at what dose, in whom, under what conditions, and by what mechanisms?

Hydrocodone is a semisynthetic opioid with analgesic and antitussive properties qualitatively similar to other opioid agonists. Ibuprofen is a nonsteroidal antiinflammatory agent with analgesic and antipyretic activity and is an effective, primarily peripheral-acting antiinflammatory analgesic. The objective of this clinical trial was to determine the additive analgesic effect of the combination of 15 mg hydrocodone bitartrate with 400 mg ibuprofen, relative to 400 mg ibuprofen alone and placebo, in the treatment of postoperative pain. The single-dose analgesic efficacy of the combination of hydrocodone bitartrate with ibuprofen was compared with ibuprofen alone and placebo in 120 patients with moderate or severe postoperative pain after abdominal surgery. Analgesia was measured during the 6-hour period after dosing based on onset of relief, hourly and summary variables, and duration of effect. A significantly greater proportion of patients treated with the hydrocodone/ibuprofen combination reported onset of relief compared with ibuprofen or placebo; however, the distribution functions for time to onset of relief did not differ among treatments. Hydrocodone with ibuprofen and ibuprofen alone were significantly more effective than placebo for all measures of analgesia. The combination of hydrocodone with ibuprofen was significantly superior to ibuprofen for all hourly analgesic evaluations, weighted sum of pain intensity differences (SPID), total pain relief (TOTPAR), and global rating of study medication. No patients in the hydrocodone with ibuprofen group required analgesic remedication during the 6-hour study period, compared with 25% and 82% in the ibuprofen and placebo groups, respectively. The analgesic superiority of 15 mg hydrocodone bitartrate combined with 400 mg ibuprofen compared with 400 mg ibuprofen alone was demonstrated across many efficacy variables.     

Virological characterization and liver histology in HCV positive subjects with normal and elevated ALT levels

In a retrospective study of the pattern of drugs used in the initial treatment of hypertension, 300 case notes of hypertensive patients attending medical clinics at the Korle-Bu Teaching Hospital, Accra and whose treatment were initiated during the period 1973-1993, were reviewed. The mean age of patients was 55 years, mean pre-treatment systolic and diastolic pressures were 179.5 +/- 25. 5 and 108.5 +/- 14.2 mm Hg, respectively, with 85% of patients being female. The frequencies of individual drugs prescribed for the initial treatment of hypertension were: diuretics (90%), reserpine (46%), methyldopa (31%), and propranolol (30%). Single drug treatment was prescribed for 18%, two drugs for 60% and three or more (multiple drugs) for 22% of patients. The mean number of drugs per patient was 2.2 Patients prescribed multiple drugs had pre-treatment systolic and diastolic blood pressures which were significantly (p < 0.01) higher than those prescribed 2 drugs which were, in turn, higher (p < 0.001) than those prescribed single drugs. The results showed that during the period 1973-1993, diuretic based "stepped care" therapy was the main first line anti-hypertensive drug management regime. "Old" anti-hypertensive drugs were more commonly used than newer ones. The cost and availability drugs and the pretreatment blood pressure were probably the main determinants of the choice of the type and number of drugs prescribed.     

Severity and impact of pain after day-surgery

PURPOSE: To assess the intensity, duration and impact of pain after day-surgery interventions. Predictors of pain severity were also evaluated along with the quality of analgesic practices and patient satisfaction. METHODS: Eighty-nine consecutive day-surgery patients completed self-administered questionnaires before leaving the hospital and at 24, 48 hr and seven days after discharge. The survey instrument was composed of 0-10 pain intensity scales, selected items of the Brief Pain Inventory, of the Patient Outcome Questionnaire and of the Barriers Questionnaire. Analgesic intake in hospital and at home was recorded along with the use of other pain control methods. RESULTS: Forty percent of the patients reported moderate to severe pain during the first 24 hr after hospital discharge. The pain decreased with time but it was severe enough to interfere with daily activities in a substantial number of patients. The best predictor of severe pain at home was inadequate pain control during the first few hours following the surgery. More than 80% of the participants were satisfied with their pain treatment. However, one patient in four (25%) needed contact with a health care provider because of pain at home. Many patients (33% to 51%) reported that instructions about pain control were either unclear or non-existent on several aspects. Medication use was low overall. Thirty-two percent of the patients did not take any pain medication during the first 24 hr after discharge although almost half of them (46%) rated their pain > or = 4. The most common concerns patients had about using pain medication were fear of drug addiction and side effects. CONCLUSION: The severity and duration of pain after day-surgery should not be underestimated. Aggressive analgesic treatment during the hospital stay should be provided along with take-home analgesia protocols and comprehensive patient education programs.     

Postoperative epidural infusion of morphine and bupivacaine is safe on surgical wards. Organisation of the treatment, effects and side-effects in 2000 consecutive patients

BACKGROUND: There was an obvious need to improve the quality and safety of our postoperative pain treatment and to introduce an improved routine service on surgical wards. METHODS: It was decided to use postoperative epidural infusion of morphine 0.04 mg/ml and bupivacaine 2.5 mg/ml (0.25%) 4-8 ml/h as pain relief after major surgery. An education programme was run emphasising the benefits, side-effects and the importance of regular monitoring of pain intensity, vital functions (respiratory rate, blood pressure, heart rate), motor function of the legs and the need for additional drugs in order to detect side-effects as well as lack of adequate analgesic effect. A detailed observation sheet was used collecting information every 2 h throughout the epidural treatment period in order to secure monitoring and adjustment of the treatment. Close contact was maintained with the wards. RESULTS: We present a detailed analysis of our first 2000 postoperative patients, mainly after orthopaedic (46.1%), gastrointestinal (32.0%), urologic (8.7%) and vascular (8.5%) surgery. Duration of the treatment was less than 24 h in 41.4% and more than 48 h in 29.7%. Pain relief was adequate in most patients, best after vascular surgery in the lower extremities (mean VAS 0.15/10.0 (95% confidence interval 0.09-0.23)) and less after gastrointestinal (mean VAS 0.49/10 (0.43-0.54)) and thoracic surgery (mean VAS 0.59/10 (0.38-0.81)). The infusion was stopped due to respiratory depression in 3 patients (0.15%). Four (0.2%) had systolic blood pressure < 80 mmHg and had to be treated with vasopressors. A total of 56 (2.8%) patients were considered to be problem patients due to excessive sedation (0.4%), hypotension (0.7%), respiratory depression (1.6%) or lower extremity paralysis (0.05%). All patients had urinary catheter until 6 h after termination of the epidural treatment. One patient had the epidural catheter accidentally placed subarachnoidally and experienced severe respiratory depression. No permanent sequelae were recorded in the postoperative patients, but 2 traumatised patients developed epidural abscesses after 3 weeks of treatment, which resulted in lower extremity paralysis. Late response to the warning signs might have contributed to the irreversible paraplegia. CONCLUSION: Our experience with this postoperative epidural analgesia regime is favourable. It has been easy to administer and monitor. Pain relief was excellent, side-effects were few and picked up by the established routines followed by the ward staff except in the 2 trauma patients who developed epidural abscesses. The staff on the surgical wards were motivated for this kind of work. Education and strict surveillance routines are mandatory in order to secure prompt action when warning signs develops (e.g. lower limb paralysis).     

Pre-emptive analgesia from intravenous administration of opioid: no effect with pentazocine

The influence of timing of administration of preoperative pentazocine on pain and analgesic requirements after surgery was studied in 46 patients undergoing total abdominal hysterectomy. Twenty-three patients received thiamylal 5 mg.kg-1 on induction of anesthesia, followed by pentazocine 30 mg or 60 mg before surgical incision (group A). Twenty-three control patients received pentazocine 30 mg or 60 mg, 5 min after abdominal incision (group B). The visual analogue scales for pain 24 h after operation were 6.0 cm at 30 mg dose in group A or 5.3 cm at 60 mg dose in group A and 5.7 cm at 30 mg dose in group B or 4.7 cm at 60 mg dose in group B. There were no differences in the visual analogues scales. Pentazocine consumption in the first 24 h after surgery was 67.5 mg at 30 mg dose in group A or 52.5 mg at 60 mg dose in group A and 70.9 mg at 30 mg dose in group B or 51.8 mg at 60 mg dose in group B. We conclude that postoperative pentazocine consumption and pain scores are no different when pentazocine is given before or after skin incision for abdominal hysterectomy and that there is no clinically useful pre-emptive analgesic effect with these doses of pentazocine.     

Respiration and circulation after total hip replacement surgery. A comparison between parenteral analgesics and continuous lumbar epidural block

The cardiopulmonary effects of two different types of postoperative analgesic regimes were compared in 31 cardiorespiratorily healthy patients subjected to total hip replacement surgery. The investigation was performed preoperatively on the morning of the day of surgery and during the first 3 days postoperatively. All patients received continuous lumbar epidural analgesia preoperatively, during surgery and up to the end of the first measurement period, which started 2.5 h after surgery. Ten patients were subseuqently given pentazocine (Fortalgesic) intramuscularly on demand for pain relief throughout the investigation, while 14 patients received 0.4% plain lidocaine (Xylocain), and seven patients 0.4% lidocaine with adrenaline (1/400,000) as a continuous lumbar epidural drip for analgesia thorughout the investigation. It was confirmed that the operative procedure itself did not significantly influence the postoperative arterial oxygenation, while the type of postoperative analgesic regimen was of considerable importance in this respect. Thus, patients given pentazocine showed a significant increase in pulmonary venous admixture, due both to an increase in true shunt and to an increase in ventilation/perfusion disturbances. This pattern of poor pulmonary function still persisted on the third postoperatively. In patients given an epidural block no significant changes in pulmonary venous admixture were noted postoperatively, and thus there was no reduction in PaO2. All patients, irrespective of the type of analgesic regimen used, had a significantly increased cardiac index and oxygen uptake postoperatively, although patients given an epidural block showed a greater increase in cardiac index, and thus a tendency towards a more hyperkinetic circulation than those given pentazocine.     

Epidural morphine plus ketamine for upper abdominal surgery: improved analgesia from preincisional versus postincisional administration

Increased postoperative pain may be caused by central nervous system plasticity, which may be related to actions of N-methyl-D-aspartic acid (NMDA) receptors on neurons in the dorsal horn of the spinal cord. Opioids act mainly on presynaptic receptors and reduce neurotransmitter release, while ketamine antagonizes NMDA receptors and prevents wind-up and long-term potentiation. Thus, we postulated that central nervous system sensitization would be prevented more effectively by the preoperative use of these two drugs simultaneously, and the effect of preemptive analgesia would be demonstrated. Ketamine, 60 mg, and morphine, 2 mg, were injected epidurally through an indwelling catheter that was inserted at the T7-8 interspace in 60 ASA physical status class 1-2 patients. The drugs were injected before induction of anesthesia (Group 1; n = 30) or immediately after removal of a surgical specimen (Group 2; n = 30). An additional 2 mg of morphine was injected when the patients complained of resting pain. The analgesic effect was assessed by the time from first analgesic injection to second dose and the number of patients who needed supplemental injections. Complications were also noted. The duration of analgesia was longer (P < 0.01) in Group 1 (31.1 +/- 16.0 h) than in Group 2 (21.1 +/- 12.0 h), and the proportion of patients who needed supplemental injections was decreased (P < 0.05) in Group 1 (56.7%) compared with Group 2 (90.0%). The incidence of adverse effects was not different between the two groups. In conclusion, preoperative administration of morphine and ketamine is more effective in reducing postoperative pain than it is when given during the operation.     

Molecular cloning, expression, and functional characterization of novel mouse sulfotransferases

STUDY OBJECTIVE: The present study was performed to determine the influence of a perioperative myocardial infarction on long-term mortality in patients who have undergone elective vascular surgery. STUDY DESIGN: This was a 4-year follow-up of patients who had undergone elective vascular procedures at a Veterans Affairs Medical Center. Between January 1989 and December 1990, 115 consecutive patients underwent surgery for either an expanding abdominal aortic aneurysm (AAA) (38%) or for pain in the lower extremities (62%). RESULTS: Vital status at 4 years postsurgery was determined for all patients. Thirty-day postoperative mortality was 3%, while estimates at 1, 2, 3, and 4 years were 19%, 26%, 35%, and 39%, respectively. Of the 45 patients who died within 4 years following surgery, the major causes of death were cardiac (40%), cancer (18%), cerebrovascular (13%), and peripheral vascular disease (11%). Univariate predictors of 1-year mortality on preoperative evaluation were an abnormal ECG, moderate or greater sized exercise thallium defect and left ventricular ejection fraction < or =40%, and a perioperative myocardial infarction. Univariate predictors of 4-year mortality were non-AAA surgery and diabetes mellitus. Perioperative myocardial infarction was a marginally significant independent predictor of 1-year mortality (p=0.06), while the need for non-AAA surgery was a strong independent predictor at 4 years. CONCLUSIONS: Cardiac mortality is the major cause of late death among patients undergoing elective vascular surgery. Although preoperative indicators of symptomatic coronary artery disease and nonfatal perioperative myocardial infarction identified those individuals at increased mortality in the first postoperative year, the extent of vascular disease at presentation may be a more important determinant of long-term survival. A randomized trial in such patients is needed to assess the best strategy for treating patients with coexistent coronary artery and vascular diseases.     

A close family resemblance: the importance of structure in understanding cytochromes P450

OBJECTIVE: To compare the experience of pain and treatment of pain in cognitively impaired and cognitively intact older adults after surgical repair of a hip fracture. DESIGN: Prospective comparative survey design. PARTICIPANTS: A convenience sample of 88 hip fracture patients (53 cognitively impaired, 35 cognitively intact) from three Midwestern urban hospital orthopedic units was interviewed between days 2 and 5 postoperatively. Subjects whose Folstein Mini-Mental State Exam (MMSE) score was less than or equal to 23 were categorized as impaired. RESULTS: Pain report and intensity did not differ significantly between the two groups. One-third of the subjects in both groups rated pain as severe or worse. Cognitively impaired subjects scored significantly higher on the Checklist of Nonverbal Pain Indicators observed with movement (CNPI-m) than did cognitively intact subjects. Cognitively impaired subjects received significantly less opioid analgesics than cognitively intact subjects in the first and second 48 hours postoperatively. Both groups received less than 25% of the mean prescribed amount of opioid analgesics. Age, MMSE, and CNPI-m score accounted for 27% of the variance in the amount of opioid analgesic administered in the first 48 hours postoperatively. CONCLUSIONS: Pain is treated poorly in older postoperative patients. Cognitive impairment and age strongly influence the amount of analgesic nurses administer to older patients after surgical repair of hip fracture. Provision for patient comfort is a fundamental ethical obligation of healthcare providers. Clinicians need to pursue this goal more aggressively, especially for cognitively impaired, postoperative older adults.